How do you solve a problem like Fiona?

Faint murmurs about the problems being created by the incredible complexity of ICT operations planned for Perth’s Fiona Stanley Hospital were heard as far back as 2011, but it wasn’t until June last year that it was officially announced that the hospital’s opening would be delayed by six months. While FSH’s problems are now out in the open due to a parliamentary inquiry, many fear that the whole drama may have a negative effect on other health infrastructure in the state.

When it was first announced back in 2009, it was billed as WA’s first paperless hospital, a technological and ecological marvel to behold, a new hospital for the digital age where information technology would seamlessly integrate with communications infrastructure to provide world’s best practice in health service provision near the gently flowing waters of the Swan.

Most people with a distaste for spin would have seen these claims as the usual marketing gumpf, but at the time, it was not a stretch to accept that the new Fiona Stanley Hospital was going to be a pretty great facility. For the health IT industry, it was the chance to show off some of the best technology around in terms of wireless infrastructure, robotics and cutting-edge clinical software.

That might still turn out to be true, but there is now no doubt that it is this super-duper ICT that has held up the opening of the hospital. In April, a bipartisan parliamentary committee made short shrift of the excuses of Health Minister Kim Hames and former WA Health director-general Kim Snowball in the More than Bricks and Mortar report into the commissioning of the hospital, revealing that it was obvious as far back as 2012 that there was no way FSH would open on schedule. The blame for the delay was placed squarely on the complexity of the ICT.

“Over time, there was a litany of reports ... [showing that] this was falling behind significantly and there were delays in recognising and conceding we were never going to deliver a hospital, not in April 2014,” committee chairman and Liberal MP Graham Jacobs said. “It was never going to happen. If the recognition of the delays, backed up by early reports, was actually recognised, a lot of the costs could have been mitigated.”

Dr Hames rejects the amount, but the parliamentary committee puts the cost of the delay in opening the hospital, including extra money for IT and staff wages, at an eye-watering $330 million. More money will be needed for IT – the government allocated an extra $40m in the May state budget – and that might not be the end of it.

“We need to make sure the very complex and difficult IT system that is required to ensure Fiona Stanley Hospital works safely for patients who come through the door, is paid for,” Dr Hames told Parliament. “We will put up the funds for whatever is required.”

Former WA under-treasurer Tim Marney probably put it best when he told the committee’s inquiry in February that the best of breed approach taken in kitting out FSH was probably the wrong one.

“You never build stuff that you can buy off the shelf,” Mr Marney, now the state’s mental health commissioner, told the committee. “You never build bespoke stuff that then has to be integrated with generic products. You change your business processes rather than changing the systems to suit the business processes. You never do big bang, because big bang goes boom.”

Best of breed

It is possible to open a new hospital with best-of-breed clinical systems but what that means is enormous complexity, and very few hospitals are capable of the massive integration task. Richard Royle, executive director of UnitingCare in Queensland, which is building a fully digital hospital at Hervey Bay on a much smaller scale than the 783-bed FSH, recently said he had decided on the opposite approach, plumping for an integrated EMR from Cerner that has only five other clinical interfaces, including those to pathology and radiology.

“My understanding from (Dr Hames) is that there are 158 interfaces at Fiona Stanley,” Mr Royle says. “158. They have a best of breed model [but] history is showing that the more interfaces you have to build into a system, the more challenges you will have. So what we have done is the opposite.”

The original plan for FSH was to have an EMR ready to go when the first patients were wheeled in, with interfaces to pathology, PACS/RIS, patient administration, pharmacy, clinical specialties, information management and reporting, identity management and data centres, all running off a wide area network built by BT. This is still the plan, but a big-bang EMR is not yet in sight.

The hospital that was first announced as having no storage space for paper medical files is now going to have to find some, and the identity management system is also in doubt, with the WA government announcing in late June that the $6 million it had spent trying to design a role-based, single sign-on smartcard for physical and computer access to the hospital was wasted because the solution doesn’t work.

While the problems of Fiona Stanley Hospital can be overcome, for many working in the WA public health sector the real problem lies in the flow-on effects on other planned infrastructure, particularly the new Perth Children’s Hospital that is due to open in late 2015. Several sources have told Pulse+IT – and Mr Marney backed this up in his comments to the committee – that the EMR chosen for Fiona Stanley was to have influenced the choice for the new kids’ hospital.

It is now highly likely that an off-the-shelf system will be chosen with none of the integration hassles that FSH has to wrestle with. Two industry sources have told Pulse+IT that US EMR giant Epic is the favoured candidate for the kids’ hospital, but that the company might have second thoughts after the dramas FSH has experienced so publicly. Epic, which recently won the tender for Melbourne’s Royal Children’s Hospital, is used widely in paediatric care in the US but has not yet been implemented anywhere in Australia.

Tendering for other elements of FSH has also been problematic. The planned closed-loop medications management system, which includes pharmacy robots, automated guided vehicles and automated medication units as well as prescribing software and interfaces with the WebPAS patient administration system, the LIS and RIS systems and iPharmacy, is a huge undertaking that only the largest companies can handle, ruling out many smaller vendors that can offer quality software systems but not the whole hardware deal. The tender for that system is still open.

Pissed off public servants

A lot of the problems seem to come back to poor planning. The full contract with Serco, which is in charge of building and operating the hospital on the government’s behalf, is worth $4.3 billion over 20 years, $2 billion of which is the actual build of the hospital. However, Mr Marney told the February committee inquiry that Treasury had only been given two weeks to review the contract before it went to cabinet, and that Treasury was quite rightly “pissed off” about it.

Dr Hames rejected this in WA’s parliament, saying that a person contracted to Treasury was on the organising committee the whole time. “The under-treasurer was, to use his words, ‘pissed off’ in the end with the time he had to look at the final contract, but I can tell members that a few people in health might have been ‘pissed off’ with him as well, in terms of how a very detailed and complex contract was worked through with Treasury.”

Former director-general Kim Snowball also defended his role in the contract negotiations and planning for the hospital. “Those being criticised are the same people who have worked incredibly hard to deliver for the state, including the Treasury, the biggest health infrastructure project of all time, on time and on budget in Fiona Stanley Hospital,” he said.

“In fact all of the major projects under construction in health were on time and on budget at the time I left the role. This doesn’t happen by accident, but by good, solid and careful management.”

While the reasons are unclear, it is pertinent to note that WA has not had a permanent director-general for health since Mr Snowball resigned in December 2012, standing down officially the following March. Nor has there been a permanent appointment as CIO of Health Information Network (HIN), the WA Health agency that oversees clinical IT. Bill Leonard was appointed as acting CIO in January after Andy Robertson stood down from the role, also acting, after just over a year.

Lack of integration

Not much of this should have come as a surprise to experts in the health IT field. In fact, Di Mantell, the hospital’s general manager for facilities management, is quite open about the huge complexity of the hospital build and operation. While she is not in charge of clinical IT, she does have intimate knowledge of the underlying ICT infrastructure behind the project.

Ms Mantell told the eHealth Interoperability Conference in September last year that the physical building would be ready by December 2013, but that the three-month transition to its planned official opening date of April 2014 was a stretch.

“What will happen is the state rehabilitation service will close at Shenton Park and our service will open in October [2014],” Ms Mantell told the conference. “That will move about 110 patients to the new service. Then over the next three phases we will gradually build up the service until it is fully operational by April 2015.

"We have worn a lot of flack for it in the media – they are having a field day with us – but you get that. If the building is not ready then you shouldn’t open it. You only get one chance to do this properly and it’s better to delay than to find out when it’s open that something doesn’t work.”

Ms Mantell detailed the extent of the ICT infrastructure at the hospital, both clinical and non-clinical, estimating that in addition to the big-name IT systems there were about 1600 other applications that clinicians and researchers – the West Australian Institute of Medical Research (WAIMR) is co-located on the Fiona Stanley campus – wanted to bring with them.

“We do have a pervasive wireless technology network, we do have medical equipment that has information systems installed, we will have RTLS, we are working towards enabling electronic medical records, we will have telehealth that is available across a diverse number of sites in the building, and we’re looking at secure and seamless interoperability,” she said.

“However, we are well aware that up until now what we felt was progressing comfortably and what we felt was locked down is still being resolved at different levels by different people.

“We will have those things I just mentioned, but will we have a full digital record when we walk in? No, we won’t. Will we have a full closed-loop medication management system? No, we won’t. But are we finally on the journey because we’ve got everybody on the same page to get people there? Yes, we will.”

A spokesperson for the hospital says it is currently finalising a range of clinical ICT applications for production, including some that have been developed in-house and those which have been procured externally.

These applications include:

  • A digital medical record provided by Core Medical Solutions. FSH say this will complement existing clinical information systems and will include a PCEHR viewer, to be implemented at a later stage
  • CSC’s webPAS patient administration system, which is being rolled out statewide
  • CSC’s iCM system, which provides a common clinical record across metropolitan health services in WA
  • A Notifications and Clinical Summaries (NaCS) system, which has been designed in-house to send discharge summaries to GPs and to the PCEHR using secure message delivery
  • A closed loop medication management solution, which is still out for tender
  • Provision for an intensive care clinical information system.

“FSH will utilise the existing Ultra LIS and AGFA PACS/RIS systems that currently provide a common patient record across the metropolitan health services,” the spokesperson says. “General practitioner referrals will be processed through Central Referral Services.”

Posted in Australian eHealth

Comments   

# Kate McDonald 2014-08-19 20:19
Posted on behalf of Associate Professor Terry Hannan
Consultant physician and health informatician
University of Tasmania


In response to the article on the Fiona Stanley Hospital I would like to make the following brief comments. It could take a lengthy dissertation however I hope I can make my points briefly.

Let me start with a previous period when I was appointed in the 1990s as the Chair of Medical Informatics at a large regional teaching hospital in NSW which lacked the following;
  • *An office for my position which meant they had no idea of the “value’ of the position
    *NO MEDICAL RECORD STORAGE AREA as they were going to have a paperless hospital.


More than 20 years later they are a hospital requiring paper.

So this brings me to the wonderful statement provided to me by a world eminent health informatician from the Regenstrief Institute in Indianapolis, Dr Marc Overhage. It reads, "your hospital will be paperless when your toilet is paperless”.

Therefore if the intention is to build ‘paperless’ from the start then the health information systems will fail to improve care and be an enormous waste.

A multitude of world-wide examples of this exist. There are examples here in Australasia where we have terabytes of ‘scanned records’ yet NO improvement in the delivery of health care. This is because they do not support “effective clinical information management” as defined by the WHO in its charter.

“There is no healthcare without management, and there is no management without information.” Gonzalo Vecina Neto Head, Brazilian National Health Regulatory Agency

Therefore here are some fundamentals on which to build effective e-health systems.

  • COLLABORATION
    SCALABILITY
    FLEXIBILITY
    RAPID FROM DESIGN
    USE OF STANDARDS
    SUPPORT HIGH QUALITY RESEARCH
    WEB-BASED AND SUPPORT INTERMITTENT CONNECTIVITY
    LOW COST: preferably free/open source
    CLINICALLY USEFUL: feedback to providers and caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used.


AMPATH Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries Burke W. Mamlin, M.D. and Paul G. Biondich, M.D., M.S. Regenstrief Institute, Inc. and Indiana University School of Medicine, Indianapolis, IN

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